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How to prepare, apply and interpret a clinic time study
The study will let you know where improvements must be made so the clinic will run on time.
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Most surgeons who acknowledge that they have a problem with their practice’s patient flow usually think about doing some kind of time study. This usually goes only as far as tracking the time from start to finish of a series of exams or just using a stopwatch for the doctor’s portion of the exam. How much further you go is a question of balance. If looked at deeply, it would take as long to assess the complex choreography of the typical clinic as it would to see the patients themselves. But if you go about a time study in a shallow manner, you will not generate enough data to be of much use. In the interest of balance, here are five simple steps to conducting and using a one-time or ongoing time study in your practice.
- Acknowledge that you have a clinic flow problem.
- Develop a time-study form as a tool to measure how patient visits flow for each provider in your practice.
- Apply this tool to the appropriate sample size with the appropriate frequency.
- Assess the results as a team for each doctor in each location, and if the results are adverse, develop standards for what the results should be in the future.
- Develop and implement tactics to improve not only the pace at which patients are seen, but also the patient’s experience during a visit to your practice, the utilization of doctor, staff and facility resources, and the financial performance of the clinic.
Let us begin by examining a generic clinic time study form (Table 1). Feel free to adapt this basic form to best suit your practice; try to boil it down to a single page that can be attached to each patient’s chart and filled out as it is routed with the patient.
You will note that this form is quite generic and may need to be altered to fit the nuances of the way you see patients. For example, some older physicians, as well as doctors in young practices that do not yet have technical support, will “double-pass” patients (have the doctor see the patient twice during the same exam, before and after dilation).
| Table 1. Patient Flow Recording Sheet | |||||||||||||||||||||||||||||||||||||
USE THIS NEXT BLOCK ONLY IF THE PATIENT IS DILATED
USE THIS NEXT BLOCK WHETHER OR NOT THE PATIENT IS DILATED:
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Specifics of form
Let us discuss some of the elements on this general form.
It would be nice if every patient arrived precisely when the appointment was scheduled. When the value of line c) (Patient Timeliness) varies widely among early, on-time and late patients, the front desk becomes more “choppy” and hectic, and the clinic can take on a stop-start-stop-start pace. Some of this can be improved with explicit instructions to patients. However, in urban centers with traffic jams and parking hassles, this may be something you simply have to live with. Try to avoid the urge to appoint all patients before they can possibly be seen just so the team has no interruption in its flow. This would work well in a manufacturing plant with a delivery yard full of raw materials, but it can kill your reputation if you leave patients with an excessive Primary Waiting Time.
The Chart Prep Time is an underestimated cause of running behind in clinic. Ideally, new patients would be registered in advance over the phone and advised to come in early to complete their paperwork. When the value of line e) is excessive or highly variable, it is time to call together the involved staff and brainstorm for improvements. In extreme cases, especially at the beginning of a session and where there is little concern about third-party payment eligibility, it may help to simply start a new patient before a chart has been completely made up, and let the paperwork catch up with the patient.
The Primary Waiting Time, which is what most people think about when they say “patients have to wait a long time in our office,” is the time between when the patient is appointed to arrive in the office and when the exam is first commenced by a tech. When the average value of line g) in your clinic exceeds about 20 minutes in a general ophthalmology practice or about 30 minutes in a subspecialty practice, expect patient satisfaction to plummet; then you are starting from behind for every encounter. It is important to realize that if your patients often arrive very early for their appointments, they will perceive the Primary Waiting Time to be greater than it really is.
Total Tech Time with Patient is the time the primary technician spends with the patient in taking history and vision, measuring IOP and doing related pre-doctor work-up activity. It also includes time spent by the techs for pre-doctor special testing, even if there is a hand-off between the primary tech and a dedicated tech who only handles such testing. Note that you may wish to customize this patient flow recording sheet if providers in your practice routinely double-pass patients or order supplemental tests in the middle of an encounter. Table 2 is an example of what you might add for the latter.
Total Dilation Time is the time it reasonably takes for the patient to actually dilate, not the extra time that some practices fib about, telling fully dilated patients they are “not quite ready yet.” Feel free to use this as a somewhat legitimate dodge on the odd, out-of-control days. But try not to institutionalize exaggerations such as this. Excess Dilation Time is, of course, the extra time the patient must wait to be seen by the doctor even though he is dilated. You might think of this as the “secondary waiting time,” and next to the Primary Waiting Time, it is the time patients least tolerate.
Total Doctor Time With Patient is the actual face-to-face time the doctor is in the room with the patient. This figure is what doctors and managers often consider the most important part of the exam, but you can see in temporal terms how the doctor’s face-to-face time with the patient may only be a small part of the total visit (perhaps 10% or less).
Total times
Total Patient Transit Time is the total time the patient’s service has taken from portal to portal. An important task with this audit is to compare your actual performance for Total Patient Transit Time with Your Practice’s Targeted Total Transit Time. Are you ahead or behind? How long should it take a patient, by category, to move through the entire experience in your office, from the time he arrives to the time he walks back out the same door? Table 3 has some representative figures. Some practices will obviously be faster, and many will be slower. Total transit times in your practice may vary markedly between providers and tech teams. Use this as a starting point for suggesting your practice’s targets.
Feel free to expand on this list of exam types and agreed goals; you can even expand this table to subdivide each exam into agreed-upon time goals for providing a refraction, taking IOP or performing a visual field test. Consider developing baselines and an internal time standard for contact lens fitting and education, dispensing in the optical or performing minor procedures. You may find it helpful to put up a similar guide sheet for the skin-to-skin time of various surgical maneuvers, or for that matter, the time it takes to perform each step in prepping for and performing cataract surgery and other procedures.
The Active Time Ratio is the percent of time during a patient’s total visit to the practice when something “active” is happening: being worked up by a tech or being seen by the doctor. Note that in the typical practice, you can never reach 100% efficiency. Striving practices can typically hit 75% to 85% but not much better. Try to remember that your company is still a medical practice, not a manufacturing plant. At the other end of the spectrum, if you have a practice with an Active Time Ratio of only 40% or 50%, you have a real opportunity to reduce unproductive waiting time and a lot of patient frustration.
| Table 2. Special tests | ||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Table 3. Total patient transit time | ||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Table 4. Action grid | ||||||||||||||||||||||||||||||||||||||||||||||||||||
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Team effort
It works best to interpret the results of your clinic audit as a group exercise, not to have just the doctor or administrator study the data alone. At the least, especially if there are interdepartmental clinic flow improvements to make, the office manager should sit down with the provider, the head tech and any other department heads that are involved. They should then analyze the encounter data as a team effort.
Calculate the average patient timeliness, chart prep time, primary waiting time and other key indicators, along with the average total transit time by appointment type.
See if any patterns emerge, based on the type of patient or time of day.
Look for patterns based on techs. You may find that one tech is consistently taking back only “easy” patients or that one tech is consistently faster than others.
Look for differences among doctors in the clinic or differences between different tech teams working with the same doctor.
Remember that the raw data from this kind of study will not sort itself out. Ultimately, passing the results around to everyone in the practice involved in direct patient service will generate the best understanding of patient flow and produce the most practical opportunities for improvement.
Once you get to the point of actual tactics to employ based on the data, write these down, assign a person and deadline to every one, and monitor progress along the way. You may find it helpful to use the “action grid” format shown in Table 4 to track progress.
When to audit
How many encounters should you study, and how often should you apply this audit review? That depends on your environment and the standards you are setting for your practice. As a minimum guideline, consider auditing a full-day clinic (40 encounters or more) for every provider in your practice twice a year, even if you are satisfied with the clinical pace. The insights you gain will help you aim for the next potential level of efficiency. Because their patterns and practice loads are changing, the tempo of younger/associate providers should probably be reviewed more often. Of course, this audit process should ideally not be imposed from the top down. Any provider working in your practice should be self-motivated to improve the clinical flow and sincerely welcome not only that you monitor the clinic, but that you benchmark his performance to the tempo and flow of other doctors in the practice.
A final note about clinic time studies: Everything you observe and measure changes. A clinic that is routinely running an hour late every day might magically run on time on audit day. You may have already experienced this with past time studies. Look on the bright side; if the team is able to speed up and smooth operations when it is being audited, it proves that the team should be able to improve the rest of the time. You may find it helpful to perform surreptitious or random sampling audits each month to keep everyone on their toes or measure just one key indicator daily (such as the primary waiting time or total transit time) and reward the team for its continued improvement.
A note from the editor:
This month’s column is an excerpt from John Pinto’s upcoming book, The Efficient Ophthalmologist, published by the American Society of Ophthalmic Administrators. It will be available this summer. Mr. Pinto has no financial interest in the book.